The uninsured rate for Alabama adults with low incomes is 36 percent in rural communities and small towns, and 29 percent in metro areas. Both rates are much higher than the national averages of 26 percent for rural areas and 18 percent for metro areas. Even in states that have not expanded Medicaid to cover adults with low wages, those rates have declined on average over the last decade.

But that progress has not reached many parts of Alabama, where the uninsured rate for low-income adults in rural areas and small towns was virtually unchanged between 2008-09 and 2015-16, the report found. And the Medicaid “work requirement” plan that Alabama has submitted for federal approval would drive the uninsured rate even higher by stripping Medicaid coverage from thousands of parents in poverty. Virtually all of those parents would be left with no realistic alternative for affordable coverage.

“Not only has Alabama failed to move forward on health coverage, but now our state is seeking to move backward by leaving even more people uninsured,” Alabama Arise policy director Jim Carnes said. “Alabama should drop its cruel efforts to punish people living in poverty and focus instead on expanding Medicaid so all Alabamians can get the care they need to become and stay healthy. Medicaid expansion would save hundreds of lives, create thousands of jobs and keep rural hospitals and clinics open to serve residents across our state.”

States that expanded Medicaid saw more than three times as large a decline in the uninsured rates for low-income adults living in rural areas and small towns than non-expansion states experienced between 2008-09 and 2015-16, the report found. Nationally, the uninsured rate for low-income adults fell by more than half – from 35 percent to 16 percent – in rural areas and small towns in states that expanded Medicaid. For states that have not expanded, the decline was much smaller: from 38 percent to 32 percent.

“Medicaid expansion would reduce the uninsured rate for residents across the entire state; however, the most dramatic improvement likely would be felt in small towns and rural areas of Alabama,” Georgetown CCF executive director Joan Alker said. “Improved coverage rates typically translate to a more stable health care system and help rural areas and small towns maintain availability of health care providers in areas where shortages are all too common. Access to rural health providers is especially important to women of child-bearing age and those with chronic conditions like asthma.”

In Alabama and elsewhere, jobs tend to be scarcer in rural areas and small towns, meaning fewer people have health insurance through their employers. And many of the jobs available in these communities – like farming and small businesses – are less likely to come with health benefits. Ten of the 11 Alabama counties with the highest unemployment rates in July 2018 were rural counties.